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Blue Medicare Essential (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Blue Medicare Essential (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Blue Medicare Essential (HMO) in 2025, please refer to our full plan details page.
Blue Medicare Essential (HMO) is a HMO plan offered by Blue Cross and Blue Shield of North Carolina available for enrollment in 2025 to people living in Select North Carolina Counties. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Blue Medicare Essential (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Blue Medicare Essential (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Blue Medicare Essential (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $61.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $590.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $8300.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Blue Medicare Essential (HMO) plan has a $590 deductible for prescription drugs. After you meet the deductible, you'll pay a copay or coinsurance depending on the drug tier and pharmacy type. For example, in the initial coverage phase, you'll pay a $6 copay at a preferred pharmacy for a 30-day supply of preferred generic drugs, while you'll pay a 49% coinsurance for preferred brand drugs. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Blue Medicare Essential (HMO) plan offers a range of benefits with varying costs. Hospital stays have copays, with no copay for days 6-90. Outpatient services have copays, and ambulance services have a $275 copay. The plan covers primary care with a $5 copay, and specialist visits have a $45 copay. Preventive services and many vision and dental services have no copay. The plan covers home health services with no copay.
Inpatient Hospital See details
Inpatient Hospital coverage includes both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you will pay a $335 copay for days 1-5, and no copay for days 6-90, with no coinsurance; additional days have no copay. Inpatient Hospital Psychiatric services have a $300 copay for days 1-5, and no copay for days 6-90, with no coinsurance; additional days are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services, Observation Services, Ambulatory Surgical Center (ASC) Services, Outpatient Substance Abuse Services, and Outpatient Blood Services. Outpatient Hospital Services and Observation Services have a $335 copay, while Ambulatory Surgical Center (ASC) Services have a $300 copay. Outpatient Substance Abuse Services, including both individual and group sessions, have a copay between $40 and $40. Outpatient Blood Services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Blue Medicare Essential (HMO) plan, with a $40 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Blue Medicare Essential (HMO) plan. Ground and air ambulance services each have a $275 copay, with no coinsurance, but transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the Blue Medicare Essential (HMO) plan. Emergency Services have a $100 copay, Urgently Needed Services have a $45 copay, and Worldwide Emergency Coverage has a $100 copay, Worldwide Urgent Coverage has a $45 copay, and Worldwide Emergency Transportation has a $275 copay.
Primary Care See details
The Blue Medicare Essential (HMO) plan covers primary care physician services with a $5 copay. Chiropractic, Occupational Therapy, and Physical Therapy services are covered with copays of $15, $25, and $25 respectively. Physician specialist services have a $45 copay, and mental health, psychiatric, and opioid treatment services have copays of $40 and $10, respectively. Additional telehealth benefits have a copay of $0 - $45. Podiatry services are not covered.
Preventive Services See details
Preventive Services include annual physical exams with no copay, and additional preventive services including Smoking and Tobacco Cessation Counseling, Fitness Benefit, Home and Bathroom Safety Devices and Modifications, Personal Emergency Response System (PERS), Support for Caregivers of Enrollees, and Kidney Disease Education Services with no copay. Other preventive services like Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit are covered with no copay. Health Education, In-Home Safety Assessment, Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Enhanced Disease Management, Telemonitoring Services, and Remote Access Technologies are not covered.
Hearing Services See details
Hearing Services include hearing exams, routine hearing exams, fitting/evaluation for hearing aids, prescription hearing aids, and OTC hearing aids. Hearing exams have a $45 copay, routine hearing exams have no copay, fitting/evaluation for hearing aids have no copay, and prescription hearing aids (all types) have a copay between $699 and $999, while OTC hearing aids are not covered.
Vision Services See details
The Blue Medicare Essential (HMO) plan covers vision services, including eye exams with a copay between $0 and $25, and eyewear with a 20% coinsurance for contact lenses. Routine eye exams have no copay, and other eye exam services have a $25 copay. Eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades have no copay.
Dental Services See details
Dental services include coverage for Medicare Dental Services with a $45 copay. Other services include oral exams, dental x-rays, prophylaxis (cleaning), adjunctive general services and periodontics with no copay, but fluoride treatment, restorative services, endodontics, prosthodontics, maxillofacial prosthetics, implant services, prosthodontics, fixed, oral and maxillofacial surgery, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Blue Medicare Essential (HMO) plan and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Blue Medicare Essential (HMO) plan. The coinsurance for dialysis services is 20%.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME) with 20% coinsurance, Prosthetics/Medical Supplies with 20% coinsurance, and Diabetic Equipment. Diabetic Supplies have a 0-20% coinsurance, while Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with prior authorization required. Diagnostic Procedures/Tests have a copay between $0 and $25, while Lab Services have no copay. Diagnostic Radiological Services and Therapeutic Radiological Services have a coinsurance of at most 20% and copays of at most $300 and $60, respectively. Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Blue Medicare Essential (HMO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Blue Medicare Essential (HMO) plan, but none of the sub-services are covered. This means that Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Blue Medicare Essential (HMO) plan, with prior authorization required. For days 1-20, and 61-100, there is no copay, but for days 21-60, there is a copay of $214. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) Items and Meal Benefits. Over-the-Counter (OTC) Items have no copay, and Meal Benefits also have no copay and require a doctor's referral. Acupuncture, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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